RG is a 50 year old insulin-dependent Diabetic man referred by his podiatrist and internist for further management of gangrenous toes and a non-healing ulcer on his right foot.He already has had amputation of several right toes prior to seeing us, and at the time of evaluation was looking at a potential below-knee amputation.
Vascular exam was notable for good right and left popliteal pulses , but absent pedal pulses bilaterally. There were faint Doppler signals in the dorsalis pedis and posterior tibial vessels bilaterally. Ankle-brachial index was falsely elevated because of calcified vessels . Arterial duplex imaging revealed that the right leg had mimimal flow below the knee, and that the left leg had a significant stenosis in the only vessel that was patent to the foot.
Peripheral angiography documented patent aorto-iliac vessels, and good runoffs to the below knee level bilaterally. On the right leg, the anterior and posterior tibial arteries were occluded, and the peroneal artery had interrupted flow to the pedal vessels. A similar anatomy was documented on the left leg.
The patient was brought back for angioplasty and stenting .He had successful opening of his peroneal artery and placement of four drug-eluting Cypher stents , with restoration of direct line flow, and a palpable posterior tibial pulse. He was sent home the following morning on anti-platelet therapy. At the time of publication, he is six months out, and has required only a trans-metatarsal amputation of the right foot [due to the previously documented gangrenous toes]. He has had successful salvage of the rest of his leg and foot.
COMMENT
Percutaneous treatment of critical limb ischemia results in limb salvage.Conventional treatments are ineffective.Amputation is associated with a 30% two year mortality,with an otherwise a severe impact on quality of life. 200,000 amputations are performed annually.
The pimary goal of limb-salvage angioplasty is freedom from major amputation, and requires the restoration of continuous in- line flow to the foot.Pulstatile flow equals wound healing.Patients with critical limb ischemia typically present with either multi-level lesions, or high-grade stenoses or occlusions of all tibioperoneal vessels.
Aggressive endovascular treatment of infra-popliteal disease results in limb-salvage in a high percentage of cases.Numerous treatment options are available which allow one to tailor the therapy for the clinical circumstances and anatomic conditions. Data continues to evolve favorably.
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